Marcas y Nombres Comerciales

Based on the EAU guidelines published in 2007 (ISBN-13:978-90-70244-59-0), the following text presents the findings of a comprehensive update produced as a collaborative effort by the ESIU (a full EAU section office), the Urological Association of Asia, the Asian Association of UTI/STD, the Western Pacific Society for Chemotherapy, the Federation of European Societies for Chemotherapy and Infection, and the International Society of Chemotherapy for Infection and Cancer. This text was recently published as “The European and Asian guidelines on management and prevention of catheter-associated urinary tract infections” (1). Since the complete document is available online, only the abstract and a summary of the recommendations are presented here.

6.1

Abstract

We surveyed the extensive literature regarding the development, therapy and prevention of catheter-associated UTIs (CAUTIs). We systematically searched for meta-analyses of randomised controlled trials available in Medline, and gave preference to the Cochrane Central Register of Controlled Trials, and also considered other relevant publications, rating them on the basis of their quality. Studies were identified through a PubMed search. The recommendations of the studies, rated according to a modification of the US Department of Health

and Human Services (1992), give a close-to-evidence-based guideline for all medical disciplines, with special emphasis on urology, in which catheter care is an important issue.

The survey found that the urinary tract is the commonest source of nosocomial infection, particularly when the bladder is catheterised (LE: 2a). Most CAUTIs are derived from the patient’s own colonic flora (LE: 2b) and the catheter predisposes to UTI in several ways. The most important risk factor for the development of catheter-associated bacteriuria is the duration of catheterisation (LE: 2a). Most episodes of short-term catheter- associated bacteriuria are asymptomatic and are caused by a single organism (LE: 2a). Further organisms tend to be acquired by patients who are catheterised for > 30 days.

The clinician should be aware of two priorities: the catheter system should remain closed and the duration of catheterisation should be minimal (GR: A). The use of nurse-based or electronic reminder systems to remove unnecessary catheters can decrease the duration of catheterisation and the risk of CAUTI (LE: 2a). The drainage bag should be always kept below the level of the bladder and the connecting tube (GR: B). In case of short-term catheterisation, routine prophylaxis with systemic antibiotics is not recommended (GR: B). There are sparse data about antibiotic prophylaxis in patients on long-term catheterisation, therefore, no recommendation can be made (GR: C). For patients using intermittent catheterisation, routine antibiotic prophylaxis is not recommended (GR: B). Antibiotic irrigation of the catheter and bladder is of no advantage (GR: A). Healthcare workers should be constantly aware of the risk of cross-infection between catheterised patients. They should observe protocols on hand washing and the need to use disposable gloves (GR: A).

A minority of patients can be managed with the use of the non-return (flip) valve catheters, thus avoiding the closed drainage bag. Such patients may exchange the convenience of on-demand drainage with an increased risk of infection. Patients with urethral catheters in place for > 10 years should be screened annually for bladder cancer (GR: C). Clinicians should always consider alternatives to indwelling urethral catheters that are less prone to causing symptomatic infection. In appropriate patients, suprapubic catheters, condom drainage systems and intermittent catheterisation are each preferable to indwelling urethral

catheterisation (GR: B). While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended (GR: A), except for some special cases. Routine urine culture in an asymptomatic catheterised patient is also not recommended (GR: C) because treatment is in general not necessary. Antibiotic treatment is recommended only for symptomatic infection (GR: B). After initiation of empirical treatment, usually with broad-spectrum antibiotics based on local susceptibility patterns (GR: C), the choice of antibiotics might need to be adjusted according to urine culture results (GR: B). Long- term antibiotic suppressive therapy is not effective (GR: A).

6.2

Summary of recommendations

Recommendation gR

General aspects

1. Written catheter care protocols are necessary. B

2. Health care workers should observe protocols on hand hygiene and the need to use disposable gloves between catheterised patients.

A

Catheter insertion and choice of catheter

3. An indwelling catheter should be introduced under antiseptic conditions. B 4. Urethral trauma should be minimised by the use of adequate lubricant and the smallest

possible catheter calibre.

B 5. Antibiotic-impregnated catheters may decrease the frequency of asymptomatic bacteriuria

within 1 week. There is, however, no evidence that they decrease symptomatic infection. Therefore, they cannot be recommended routinely.

B

6. Silver alloy catheters significantly reduce the incidence of asymptomatic bacteriuria, but only for < 1 week. There was some evidence of reduced risk for symptomatic UTI. Therefore, they may be useful in some settings.

B

Prevention

7. The catheter system should remain closed. A

8. The duration of catheterisation should be minimal. A 9. Topical antiseptics or antibiotics applied to the catheter, urethra or meatus are not

recommended.

A 10. Benefits from prophylactic antibiotics and antiseptic substances have never been established,

therefore, they are not recommended.

A 11. Removal of the indwelling catheter after non-urological operation before midnight might be

beneficial.

B 12. Long-term indwelling catheters should be changed at intervals adapted to the individual

patient, but must be changed before blockage is likely to occur, however, there is no evidence for the exact intervals of changing catheters.

B

13. Chronic antibiotic suppressive therapy is generally not recommended. A 14. The drainage bag should always be kept below the level of the bladder and the connecting

tube.

B

Diagnostics

15. Routine urine culture in asymptomatic catheterised patients is not recommended. B 16. Urine, and in septic patients, also blood for culture must be taken before any antimicrobial

therapy is started.

C 17. Febrile episodes are only found in < 10% of catheterised patients living in a long-term facility.

It is therefore extremely important to rule out other sources of fever.

A

Treatment

18. While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter- associated bacteriuria is not recommended, except in certain circumstances, especially before traumatic urinary tract interventions.

A

19. In case of asymptomatic candiduria, neither systemic nor local antifungal therapy is indicated, but removal of the catheter or stent should be considered.

A/C 20. Antimicrobial treatment is recommended only for symptomatic infection. B 21. In case of symptomatic CAUTI, it might be reasonable to replace or remove the catheter

before starting antimicrobial therapy if the indwelling catheter has been in place for > 7 days. B 22. For empirical therapy, broad-spectrum antibiotics should be given based on local

susceptibility patterns.

C 23. After culture results are available, antibiotic therapy should be adjusted according to pathogen

sensitivity.

24. In case of candiduria associated with urinary symptoms, or if candiduria is the sign of systemic infection, systemic therapy with antifungals is indicated.

B 25. Elderly female patients may need treatment if bacteriuria does not resolve spontaneously after

catheter removal.

C

Alternative drainage systems

26. There is limited evidence that postoperative intermittent catheterisation reduces the risk of bacteriuria compared with indwelling catheters. No recommendation can be made.

C 27. In appropriate patients, a suprapubic, condom drainage system or intermittent catheter is

preferable to an indwelling urethral catheter.

B 28. There is little evidence to suggest that antibiotic prophylaxis decreases bacteriuria in patients

using intermittent catheterisation, therefore, it is not recommended.

B

Long-term follow up

29. Patients with urethral catheters in place for > 10 years should be screened for bladder cancer. C

6.3

Reference

1. Tenke P, Kovacs B, Bjerklund Johansen TE, et al. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Int J Antimicrob Agents 2008;31

Suppl 1:S68-78.

http://www.ncbi.nlm.nih.gov/pubmed/18006279